Pharmacy teams should use the ‘95 per cent less harmful’ figure to encourage smokers to make the switch to vaping, says Public Health England.

Smoking causes about 80 per cent of deaths from lung cancer, bronchitis and emphysema, as well as approximately 14 per cent of heart disease mortality, according to Action on Smoking and Health (ASH). Despite a marked decline in popularity in recent years, about 16 per cent of adults in England still smoke.

In its recent report, ‘Evidence review of e-cigarettes and heated tobacco products 2018’, Public Health England (PHE) concludes that e-cigarettes pose “only a small fraction of the risks of smoking”. For example, published data suggest that the lifetime carcinogenic potential of vaping is “largely under 0.5 per cent of the risk of smoking”.

Further studies are needed to compare the risks of cardiovascular and lung diseases, but PHE says that the risks associated with e-cigarettes are probably “substantially below” those linked to smoking.

Moreover, e-cigarettes probably contributed to tens of thousands of people stopping smoking who would probably not have otherwise quit. PHE estimates that between 16,000 and 22,000 additional people quit each year because of e-cigarettes. Depending on the assumptions in the model, however, e-cigarettes might result in up to 57,000 additional people quitting smoking a year in England alone.

Yet myths and misconceptions create a smokescreen around the benefits of e-cigarettes, which pharmacy teams can help disperse. For example, only half of smokers believe that vaping is less harmful than smoking – a belief that falls to a third among smokers who have never tried e-cigarettes.

Similarly, only half of adult smokers believe that nicotine replacement therapy (NRT) is any less harmful than smoking – just 8-9 per cent of adults understand that nicotine is not responsible for most smoking-related harm.

Poor understanding

“It is of great concern that smokers still have such a poor understanding about what causes the harm from smoking,” said the report’s lead author Ann McNeill, professor of tobacco addiction, King’s College London. “When people smoke tobacco cigarettes, they inhale a lethal mix of 7,000 smoke constituents, 70 of which are known to cause cancer

“People smoke for the nicotine, but contrary to what the vast majority believe, nicotine causes little if any of the harm. The toxic smoke is the culprit and is the overwhelming cause of all the tobacco-related disease and death. There are now a greater variety of alternative ways of getting nicotine than ever before, including nicotine gum, nasal spray, lozenges and e-cigarettes.”

Similarly, no compelling evidence suggests that e-cigarettes are a ‘gateway’ into tobacco smoking. “Despite some experimentation with these devices among never smokers, e-cigarettes are attracting very few young people who have never smoked into regular use,” the report says. E-cigarettes do not seem to undermine the continuing decline in smoking among young people in the UK.

Could do better

Despite e-cigarettes’ popularity, there is still considerable room to improve uptake. PHE estimates that 40 per cent of smokers have not tried an e-cigarette.

“E-cigarette use has stagnated in recent years, which is hardly surprising as many smokers incorrectly believe that vaping is as harmful as smoking. We hope this report will provide the reassurance needed to encourage the 40 per cent of smokers who’ve failed to quit but never tried vaping to go ahead and switch,” says Deborah Arnott, ASH chief executive.

“ASH supports PHE’s recommendation that smokers who have struggled to quit should try vaping as an alternative to smoking, and that e-cigarettes should be made available on prescription.”

The report makes numerous other practical and policy suggestions. For instance, PHE recommends that local stop smoking services and healthcare professionals should provide behavioural support to smokers who want to quit using e-cigarettes. The National Centre for Smoking Cessation and Training recently launched a training course on e-cigarettes (elearning.ncsct.co.uk/e_cigarettes-launch).

Further research

PHE also makes numerous suggestions for further research, including:
• Monitoring adverse effects of passive vaping
• Assessing similarities and differences in addictiveness of nicotine inhalation and tobacco smoking
• Determining potential harms of inhaled nicotine, such as any long-term effects on lung tissue.

Studies should also examine why and when ex-smokers started using e-cigarettes, and factors that increase or decrease the likelihood of relapse, including comparing the risk with e-cigarettes versus other anti-smoking medications.

PHE also calls for research assessing e-cigarettes’ impact on health and economic inequalities, including among offenders and people with mental health problems.

Nevertheless, it is clear that, as PHE notes, e-cigarettes have “only a small fraction of the risks of smoking, and switching completely from smoking to vaping conveys substantial health benefits over continued smoking.” Indeed, current evidence suggests that e-cigarettes are “at least 95 per cent less harmful than smoking”.

PHE stresses that this does not mean that e-cigarettes are safe and says consumers and pharmacists should report adverse events that might be linked to e-cigarettes using the Yellow Card Scheme

Pharmacy teams can use the ‘95 per cent less harmful’ figure “ to communicate the large difference in relative risk unambiguously so that more smokers are encouraged to make the switch from smoking to vaping” and help tackle the UK’s leading cause of preventable illness and premature death.